Oral Surgery Photography and Video Consent Form

I, _______________________ (patient name), hereby authorize Dr. _______________________ and their clinical staff at _______________________ (practice name) to take clinical photographs, digital images, and/or video recordings of my oral/facial region, including related surgical procedures.

Purpose and Usage

• Clinical documentation and treatment planning
• Educational purposes for other healthcare professionals
• Scientific publication in medical/dental journals
• Marketing materials (if specifically authorized below)

Authorization Details

I understand that:

1. These images/recordings may include identifiable features of my face, mouth, teeth, and surrounding areas
2. All images will be stored securely according to HIPAA guidelines
3. My name and identifying information will remain confidential unless specifically authorized
4. I can revoke this authorization in writing at any time

Specific Usage Authorization (initial all that apply):

___ Clinical documentation and treatment planning ___ Educational presentations to healthcare professionals ___ Scientific/medical publications ___ Practice marketing materials (website, brochures, social media) ___ Other: ______________________

Duration

This authorization shall remain in effect until revoked in writing or until: _______________________ (date)

Financial Considerations

I understand I will receive no financial compensation for the use of these images/recordings.

Signatures

Patient Signature: _______________________ Date: _______________________

Witness Signature: _______________________ Date: _______________________

Practitioner Signature: _______________________ Date: _______________________